Synopsis
Stabilise suspected Mallory-Weiss bleeding, use risk-stratified early endoscopy and treat ongoing haemorrhage while addressing the precipitating retching safely.
- A Mallory-Weiss lesion is a longitudinal mucosal laceration near the gastro-oesophageal junction produced by a sudden pressure gradient during retching, vomiting, coughing or straining.
- The typical history is repeated non-bloody emesis followed by fresh haematemesis, but the sequence is absent in some patients and cannot replace endoscopy.
- Most tears stop bleeding spontaneously, yet active arterial oozing, shock, coagulopathy or major comorbidity can make haemorrhage clinically important.
- Initial care follows the same ABC, access, blood sampling, transfusion and risk-assessment principles as any acute upper-GI bleed.
- The Glasgow-Blatchford score supports pre-endoscopic risk assessment; only appropriately low-risk patients considered against local criteria should avoid admission.
- NICE advises endoscopy immediately after resuscitation for unstable severe bleeding and within twenty-four hours for other admitted upper-GI bleeds.
- A clean non-bleeding tear usually needs no endoscopic haemostasis, while active bleeding can be treated with clips, thermal methods or injection as an adjunct under expert care.
- Adrenaline injection should not be used as sole definitive haemostasis for a non-variceal lesion because combination treatment is more durable.
- Severe pain or systemic illness after vomiting suggests Boerhaave syndrome, and a negative endoscopy for bleeding does not make perforation safe to ignore.
- Preventing recurrence means treating the cause of vomiting, reviewing alcohol and medicines, and giving clear return advice rather than prescribing acid suppression automatically.
Key red flags
Several episodes of forceful non-bloody vomiting are followed by fresh haematemesis, often with less pain than the amount of blood initially suggests.
Tachycardia, hypotension, cool peripheries, delayed capillary refill, syncope, confusion or oliguria indicate significant haemorrhage requiring immediate resuscitation and escalation.
Known cirrhosis, portal hypertension, ascites, jaundice or prior varices requires the suspected-variceal pathway until endoscopy defines the source.
Disproportionate chest or upper-abdominal pain, breathlessness, fever, crepitus or pleural findings after vomiting is more consistent with perforation than an isolated mucosal laceration.
Melaena, postural dizziness or falling haemoglobin can continue after visible haematemesis stops and warrants reassessment rather than reassurance from an empty vomit bowl.
Investigation priorities
Recognise shock and response to resuscitation in real time.
Management branches
Haematemesis or melaena occurs after retching, with or without circulatory compromise.
- Assess airway, breathing and circulation, call for senior help, place appropriate large-bore IV access and monitor continuously when bleeding is severe.
- Send urgent bloods and group-and-screen, begin balanced crystalloid while blood is prepared, and activate the major-haemorrhage protocol for uncontrolled bleeding or shock.
- Review anticoagulants, antiplatelets, liver disease and comorbidity, using indication-specific reversal with haematology or cardiology input rather than indiscriminate correction.
- Calculate a pre-endoscopy risk score once immediate care is under way and refer to gastroenterology for timing, airway and location of endoscopy.